Restoration of a central incisor: direct composite Vs ceramic veneer

Can nowadays one peacefully consider restoring a central incisor with a direct composite in place of a bonded ceramic veneer? According to the therapeutic gradient, we, depending on the size of the lesion, must think before choosing a solution that is too invasive. Through two similar clinical situations of 11 requiring a restoration, we will develop both solutions taking into account such fundamental parameters as non invasive approach, periodontal respect, difficulty and the final result without neglecting the durability of this type of restoration.

Case number 1
A patient had the incisal edge of her 11 impaired by an unsightly composite restoration, as a result of a trauma that occurred ten years before.
Choice criteria:
– age: 25 years old, old trauma. The clinical examination detects no particular sensitivity.
– aesthetic requirements & expectations: medium (the restoration has been done several years ago). The patient wants to improve the aesthetic aspect of the restoration with minimum invasive intervention
– The size of the lesion is about 25% of the crown and is favorable for a direct composite restoration
– Probability of a successful outcome: good
– Difficulty: medium

Case number 2
A patient comes to the office to replace an unsatisfactory composite restoration on tooth 11, done several times after a trauma that occurred 5 years ago.
Choice criteria:
– Age: 23 years old, the composite was redone several times to the great displeasure of the patient
– Aesthetic requirement: high. The patient asks for a «final» ceramic restoration.
– The size of the lesion is more than 1/3 of the tooth. No noticeable clinical signs except little sensitivity to cold
– Probability of a successful outcome: difficult
– Difficulty: this case needs an accurate ceramic work and a very skilled lab technician. The result is even more difficult to achieve, seen that only one central incisor is to be restored, identical to tooth 21, previously bleached and has a uniform surface texture and an internal individualized structure.

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Fig.1
Clinical case no. 1
The smile picture shows the need to replace the old composite restoration on tooth 11.

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Fig.2
Color matching. Tooth 11 has to be restored with A1 color.

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Fig.3
The cross polarized picture shows the internal structure of tooth 21 that has to be reproduced.

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Fig.4
Topographic analysis of the different anatomical structures:
1. contour line
2. internal dentinal structure
3. opalescent area
4. characterization

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Fig.5
When performing a restorative procedure, use of the rubber dam is mandatory.

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Fig.6
The preparation consists of a buccal chamfer and a flat design for the palatal and the proximal areas.

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Fig.7
This picture shows the finishing line and the design of the preparation according to the orientation of the enamel prisms.

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Fig.8
A silicone index is made from a lab wax-up. LM Arte Fissura is used to create a landmark of the area to be restored.

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Fig.9
The preparation is sandblasted, the enamel is etched with 37% orthophosphoric acid and a universal bonding agent is applied.

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Fig.10
The palatal wall is built with enamel composite. Using a brush facilitates this step.

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Fig.11
Using curved metallic matrices in a vertical way helps creating proximal walls in an easy way.

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Fig.12
“The box” is now ready to be filled with dentine composite.

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Fig.13
One layer of dentine composite is applied. Excess material is removed with the LM Arte Misura tool, which creates a calibrated 0,5mm space free for buccal enamel composite.

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Fig.14
According to the previous analysis, dentin body is split in 3 mamelons with LM Arte Fissura instrument and softens with compobrush.

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Fig.15
The opalescent composite is applied between the mamelons.

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Fig.16
Characterization of the incisal edge is done.

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Fig.17
Final lightcuring is done under glycerine gel.

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Fig.18
Finishing and polishing procedure is done with finishing style burs kit and soflex discs and spirals. Final shining is done with goat brushes and Diamond Twist polishing paste.

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Fig.19
Post operative outcome, 1 week after.

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Fig.20
The 3/4 view shows the macrostructure of the restoration.

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Fig.21
3 years post op outcome after cleaning and a soft repolishing.

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Fig.22
Before / After comparison

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Fig.23
Clinical case no. 2
Intra oral view shows the lesion of 1/3 of tooth 11.

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Fig.24
Cross polarized picture shows internal structures of tooth 21. This document is mandatory and will allow the lab technician to do a realistic and natural stratification with alternation of dentin mamelons, translucent areas and amber and white characterizations of the incisal edge.

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Fig.25
The final preparation shows a finishing line far from the periodontium.

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Fig.26
Different steps of the lab work (Prothesia Lab)

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Fig.27
The different views of the feldspathic veneer shows the neat stratification work of the lab technician.

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Fig.28
Try in of the veneer shows the insertion axis.

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Fig.29
Volume and macrotexture control.

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Fig.30
Aesthetic try in. In this step, a transparent silicone is used to set the veneer on the tooth so the patient can stand up, see the final outcome and validate before the final bonding procedure.

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Fig.31
Different steps of the bonding procedure made easy by individual rubber dam installation.

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Fig.32
Direct post operative outcome, after rubber dam removal.

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Fig.33
1 week after, the cross polarized picture shows that internal structures have been well reproduced.

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Fig.34
1 week after, we can see that the gum has healed perfectly

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Fig.35
6 months after, the restoration is perfectly integrated.

Conclusions

The therapeutic decision about direct Vs indirect single incisor restoration depends on several criteria: the age of the patient, the aesthetic requirement, the probability of the result, the difficulty of conception and longevity.
In addition, an important factor added to these various parameters is the ability of the operator and his taste for aesthetic restorations. In the direct method, the operator factor is essential: it must have a precise preoperative analysis (identification of the different structures, mastery of the composites and requirement in the finishing stages). For indirect restorations, the problem moves to the laboratory level; indeed, if the dentist can quickly achieve quality tooth preparations, then the issue of the know-how of the laboratory arises. Communication and sharing of precise documentation (high definition photos, polarized photos…) will facilitate the task of the technician. Finally, the last difficulty concerns the bonding protocol which must be carried out in a rigorous way. In summary, a restoration of a central incisor, whether in direct technique with composite or indirect bonded ceramics, is a real challenge.

Bibliography

Manauta J, Salat A. Layers: an atlas of composite resin stratification. Quintessence 2012.
Gauthier Weisrock, Jean-Louis Brouillet. Le champ opératoire évidemment. L’INFORMATION DENTAIRE n° 42 – 3 décembre 2008.
Devoto W, Saracinelli M, Manauta J. Composites in every day practice: How to choose the right material and simplify application techniques in the anterior teeth JEAD, Jan. 2010.
Paris JC, Faucher AJ. Le Guide esthétique: comment réussir le sourire de vos patients. Quintessence international 2003.
Galip G. The Science and Art of Porcelain Laminate Veneers. London: Quintessence, 2003.
Carvalho RM. Effet de l’orientation des prismes sur la résistance à la traction de l’émail. Journal of Adhesive Dentistry, 2000,2:251-257
Faucher AJ, Ortet S, Camaleonte G, Weisrock G, Etienne O, Paris JC. Réussir les composites antérieurs au quotidien. Quintessence. 2017
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